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A Comparison of the Effects of Epidural Analgesia Versus Traditional Pain Management on Outcomes After Gastric Cancer Resection: A Population-Based Study

Cummings, Kenneth C. III MD, MS*; Patel, Meatal MPH; Htoo, Phyo Than MD, MPH; Bakaki, Paul M. MD, PhD; Cummings, Linda C. MD, MS; Koroukian, Siran PhD§

Regional Anesthesia & Pain Medicine:
doi: 10.1097/AAP.0000000000000079
Original Articles

Background and Objectives: Epidural analgesia may increase survival after cancer surgery by reducing recurrence. This population-based study compared survival and treated recurrence after gastric cancer resection between patients receiving epidurals and those who did not.

Methods: We used the linked federal Surveillance, Epidemiology, and End Results Program/Medicare database to identify patients aged 66 years or older with nonmetastatic gastric carcinoma diagnosed 1996 to 2005 who underwent resection. Exclusions included diagnosis at autopsy, no Medicare Part B, familial cancer syndrome, emergency surgery, and laparoscopic procedures. Epidurals were identified by Current Procedural Terminology codes. Treated recurrence was defined as chemotherapy greater than or equal to 16 months and/or radiation greater than or equal to 12 months after surgery. Recurrence was compared by conditional logistic regression. Survival was compared via marginal Cox proportional hazards regression model.

Results: We identified 2745 patients, 766 of whom had epidural codes. Patients receiving epidurals were more likely to have regional disease, be white, and live in areas with relatively high socioeconomic status. Overall treated recurrence was 25.6% (27.5% epidural and 24.9% nonepidural). In the adjusted logistic regression, there was no difference in recurrence (odds ratio, 1.40; 95% confidence interval [CI], 0.96–2.05). Median survival did not differ: 28.1 months (95% CI, 24.8–32.3) in the epidural versus 27.4 months (95% CI, 24.8–30.0) in the nonepidural groups. The marginal Cox models showed no association between epidural use and mortality (adjusted hazard ratio, 0.93; 95% CI, 0.84–1.03).

Conclusions: There was no difference between groups regarding treated recurrence or survival. Whether this is true or simply a result of insufficient power is unclear. Prospective studies are needed to provide stronger evidence.

Author Information

From the *Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic; †Department of Epidemiology and Biostatistics, Case Western Reserve University; ‡Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center; and §Department of Epidemiology and Biostatistics, School of Medicine, and Case Comprehensive Cancer Center, Population Health and Outcomes Research Core, Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH.

Accepted for publication February 17, 2014.

Address correspondence to: Kenneth C. Cummings, III, MD, MS, Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, E-30, Cleveland, OH (e-mail:

The authors declare no conflict of interest.

Supported by Case Western Reserve University/Cleveland Clinic CTSA UL1RR024989 (K.C.C.), Case Western Reserve University GI SPORE P50 CA150964 (L.C.C.), and NIH K12 CA076917 (L.C.C.).

Presented at the Anesthesiology 2013, the Annual Meeting of the American Society of Anesthesiologists, October 12–16, 2013, San Francisco, CA.

Copyright © 2014 by American Society of Regional Anesthesia and Pain Medicine.